Clinical Review & Education

Review

Toward Adenotonsillectomy in Children

A Review for the General Pediatrician
David G. Ingram, MD; Norman R. Friedman, MD

Adenotonsillectomy is one of the most common surgical procedures performed in children,

with more than half a million procedures performed annually. We provide a review of the
procedure, including indications, contraindications, perioperative issues, and current
controversies. A more in-depth discussion of indications for sleep-disordered breathing and
recurrent throat infections is performed. We provide a reasonable approach to these
conditions for the general pediatrician. Finally, we discuss selected areas of current
controversies: the role of preoperative polysomnogram, postoperative weight gain, and
effects on immune function.
JAMA Pediatr. doi:10.1001/jamapediatrics.2015.2016
Published online October 5, 2015.

denotonsillectomy is one of the most commonly performed surgical procedures in children.1 Removing the tonsils dates back to the first century CE in Rome, where inflamed tonsils were purportedly removed with fingers.2 While
adenotonsillectomy is a common procedure, rates vary both within
the United States and globally.3

Indications
The indications for adenotonsillectomy in children are detailed in an
American Academy of OtolaryngologyHead and Neck Surgery clinical practice guideline (Box).4 The 2 most common indications are
throat infections and sleep-related breathing disorder.4,5

Sleep-Disordered Breathing
Sleep-disordered breathing (SDB) is a clinical diagnosis. If a child
has signs and symptoms of SDB and results of a polysomnogram
(PSG) confirm an obstructive breathing pattern, the correct diag-

Box. Common Potential Indications for Adenotonsillectomy

Sleep-disordered breathing
Recurrent throat infections
Dysphagia or voice quality changes related to enlarged tonsils
Periodic fever, aphthous stomatitis, pharyngitis, and cervical
adenitis
Peritonsillar abscess in children with other indications for
adenotonsillectomy
Halitosis
Chronic tonsillitis unresponsive to antimicrobials
Tumor or hemorrhage of tonsils
Pediatric autoimmune neuropsychiatric disorder associated with
streptococci
Chronic group A streptococcus carriage

jamapediatrics.com

Author Affiliations: Author

affiliations are listed at the end of this
article.
Corresponding Author: Norman R.
Friedman, MD, Division of Pediatric
Otolaryngology, Childrens Hospital
Colorado, 13123 E 16th Ave, Aurora,
CO 80045 (norman.friedman
@childrenscolorado.org).

nosis is obstructive sleep apnea (OSA). Without a PSG, health care

professionals cannot diagnose OSA. The significance of positive
PSG results in the context of no symptoms of SDB depends a
great deal on the clinical context; this result is more likely to be of
clinical significance in children predisposed to OSA (eg, those
with Down syndrome, morbid obesity, or neuromuscular or craniofacial disease), in those with associated significant morbidity
(eg, pulmonary hypertension), or if the OSA is severe. In this situation we recommend referral for a sleep study. Most pediatric
otolaryngologists do not perform a preoperative PSG on an otherwise healthy child prior to adenotonsillectomy; thus, the indication for surgery in such patients is SDB, not OSA6; the major limitation of this practice is for perioperative planning. Children
diagnosed with severe OSA after PSG should be monitored more
closely owing to their increased risk for postoperative respiratory
compromise.
Both snoring and OSA are common, affecting 10% to 30%7 and
1% to 5% of children,8 respectively. Obstructive sleep apnea represents the severe end of the spectrum of SDB, which ranges from primary snoring to upper airway resistance syndrome to OSA.9,10 The
primary etiologic factor for pediatric OSA is adenotonsillar hypertrophy, especially between the ages of 2 and 7 years, when the tonsils undergo a growth phase. Untreated OSA is associated with problems in key domains of childhood health: learning, growth, behavior,
and cardiovascular health.8
Since PSG can be expensive and time-consuming and requires
properly trained staff, less than 10% of children undergo PSG prior
to adenotonsillectomy.11 While the American Academy of Pediatrics (AAP) guideline recommends formal PSG prior to adenotonsillectomy for all habitually snoring children with findings associated
with OSA,8 the American Academy of OtolaryngologyHead and
Neck Surgery guidelines do not recommend routine PSG prior to adenotonsillectomy for otherwise healthy children with tonsillar hypertrophy and SDB.11 Therefore, the appropriate role of PSG in the
diagnosis and management of SDB is still debated.
First-line treatment for SDB is adenotonsillectomy.4,8 The success rates for OSA resolution with adenotonsillectomy are vari(Reprinted) JAMA Pediatrics Published online October 5, 2015

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Adenotonsillectomy in Children

able. A meta-analysis of more than 1000 children found the rate for
OSA cure (apnea-hypopnea index [AHI] <1 event per hour) with adenotonsillectomy to be 58%.12 In a large multicenter study, 27% of
children achieved OSA cure, again defined as an AHI less than 1 event
per hour after adenotonsillectomy. Cure was less likely in children
who were older or obese or who had more severe baseline disease.13
In the first randomized clinical trial of adenotonsillectomy vs watchful waiting with supportive care (WWSC) for children with OSA (the
Childhood Adenotonsillectomy Trial [CHAT]),5 the overall success
for an adenotonsillectomy was 79%. Success was defined as an AHI
less than 2 events per hour and an obstructive apnea index less than
1 event per hour. Children with obesity, African American children,
and those with an AHI greater than 4.7 events per hour were less
likely to be cured. Of the children in the WWSC group, 47% had spontaneous resolution of their OSA at 7 months. The large differences
observed in published cure rates with adenotonsillectomy are likely
related to differences in study sample characteristics (eg, obesity status, age) and variability between laboratories in scoring of respiratory events; there is also objective evidence for publication bias, with
likely negative studies going unpublished.12
The CHAT trial results warrant special discussion.5 Generally
healthy 5- to 9-year-old children with mild to moderate OSA were
recruited from clinical settings and randomized to undergo adenotonsillectomy or WWSC. At baseline and 7 months of followup, a battery of neurocognitive tests, surveys, cardiometabolic measures, and sleep studies was performed. Results demonstrated
significant advantage for adenotonsillectomy vs WWSC for normalization of sleep study results, scores on multiple parent-reported behavioral scales, scores on SDB rating scales, and quality of life. In contrast, there were no differences in formally assessed neurocognitive
attention and executive function; results of teacher-reported behavior scales were mixed.
Multiple subsequent analyses of the CHAT data have been published. Baseline severity of OSA was found to be related to African
American race, obesity, scores on symptom scales, and environmental tobacco exposure.14,15 Investigators found that there were
no group differences in change in blood pressure, lipid, glucose, or
C-reactive protein levels.16 Complication rates for the procedure were
low, and no PSG or demographic parameters were associated with
the outcome.17 Baseline symptoms of SDB were associated with behavioral problems and poorer quality of life at baseline and were associated with change in parent ratings of behavior and symptoms
postoperatively; neither PSG measures nor SDB symptoms were associated with objective executive function at baseline or postoperative improvement.18 Improvements in quality of life measures
were greater for those undergoing adenotonsillectomy vs WWSC,
and the change in quality of life measures with surgery was minimally related to changes in AHI or oxygen desaturation index.19 Finally, children who underwent adenotonsillectomy demonstrated
greater weight gain, especially children who were overweight at
baseline.20
Taken together, the above data largely support the efficacy of
adenotonsillectomy for SDB in children, at least from the parents
subjective perspective. In addition, the results of CHAT highlight the
importance of outcomes beyond normalization of the PSG results.
Given the variable cure rates, it is important to assess for residual
symptoms of SDB postoperatively and obtain a PSG if there is clinical concern for residual disease.
E2

At a Glance
The 2 most common indications for adenotonsillectomy are
sleep-related breathing disorder and recurrent throat infections
that meet the Paradise criteria.
Sleep-disordered breathing is a clinical diagnosis based on
history of nighttime symptoms and daytime symptoms.
Obstructive sleep apnea (OSA) is the diagnosis given to a child
with sleep-disordered breathing who has undergone a sleep
study with abnormal results.
Sleep studies should be performed when the results have the
potential to alter patient management.
The Childhood Adenotonsillectomy Trial (CHAT), a randomized
clinical trial of adenotonsillectomy for children with OSA, showed
significant advantage for adenotonsillectomy vs watchful waiting
for normalization of sleep study results, scores on multiple
parent-reported behavioral scales, and quality of life.
Hospitalization is recommended for children younger than 3
years of age, those with severe OSA (defined by an apneahypopnea index >10 per hour or oxygen nadir <80%), and those
with complicated medical histories.
Routine administration of perioperative antibiotics for
adenotonsillectomy is not recommended by the American
Academy of OtolaryngologyHead and Neck Surgery.
The recommended first-line postoperative analgesics after
adenotonsillectomy are acetaminophen with or without
ibuprofen.

Recurrent Throat Infections

For the purposes of this discussion, throat infection is considered a
sore throat of either viral or bacterial origin; results of a culture may
or may not be positive for group A streptococcus.4 It is important
that throat infections be documented at the time of occurrence given
previous experience that undocumented histories of recurrent throat
infections do not forecast subsequent infections.21 The role of adenotonsillectomy in children with recurrent throat infection has been
debated, and results of clinical trials suggest that the benefit of surgery depends a great deal on the severity of infections.
Children with severe recurrent throat infection may benefit
from tonsillectomy. In this context, severe is defined by the Paradise criteria.4 The seminal trial included both randomized and nonrandomized children with severe recurrent throat infection and
demonstrated benefit of tonsillectomy vs nonsurgical treatment,
with decreased incidence of throat infection in the first 2 years following surgery.22 At the third year of follow-up, the between-group
difference was no longer significant, and, with time, children in the
nonsurgical group had fewer and less severe episodes. A recent
Cochrane review confirmed these findings.23 Taken together, these
results support adenotonsillectomy as an option for children with
severe recurrent throat infection while providing evidence for nonsurgical treatment, highlighting the importance of an individualized
approach and taking into account both physician and parent risk
thresholds for recurrent disease vs potential adverse effects of
surgery.4 In contrast to severely affected children, tonsillectomy for
those with mild or moderate recurrent throat infections is generally
not recommended. In these children, management should be
directed toward symptomatic and appropriate antimicrobial therapies rather than surgery.4 One exception is that in children with
recurrent mild or moderate throat infections but also extensive
drug allergies, surgery may be of benefit. The Figure provides a

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Adenotonsillectomy in Children

Review Clinical Review & Education

Figure. Approach to Common Indications for Adenotonsillectomy

Paradise Criteria
Frequency of sore throat
Past 1 y: 7 episodes OR
Past 2 y: 5 episodes each OR
Past 3 y: 3 episodes each
Episodes have sore throat plus:
Fever >38.3C OR
Cervical adenopathy (tender
lymph nodes >2 cm) OR
Tonsillar exudate OR
GAS positive
Each episode has been treated
with appropriate antibiotics

Recurrent sore throat

Meets Paradise criteria

OR
Has modifying factors

Each episode was documented

at the time or the clinician has
subsequently observed
2 episodes
No

Modifying Factors
Multiple antibiotic allergies
PFAPA
Peritonsillar abscess
See text for other possible
factors

Watchful
waiting with
supportive care

Yes

OR

Symptoms of SDB

Daytime symptoms
AND
Nighttime symptoms
AND
Large tonsils
AND
No selected comorbidity

Yes

Refer for
adenotonsillectomy

Nighttime
Snoring (at least
3 nights per week)
Labored breathing
Gasps or snorting
Enuresis (secondary)
Neck hyperextension
Mouth breathing
Morning headaches

Selected Comorbidities
Obesity
Down syndrome
Craniofacial abnormality
Neuromuscular disease
Sickle cell disease
Mucopolysaccharidoses

No

Polysomnogram

practical management algorithm for the common indications to

refer a child for an adenotonsillectomy evaluation.

Other Indications
While SDB and recurrent throat infections represent by far the most
common reasons for children to undergo adenotonsillectomy, there
are many other potential indications that are less well validated. Other
indications include dysphagia or voice quality changes related to enlarged tonsils24; periodic fever, aphthous stomatitis, pharyngitis, and
cervical adenitis (PFAPA)25,26; and peritonsillar abscess.4,27,28 Other
potential indications include halitosis, chronic tonsillitis unresponsive to antimicrobials, tumor or hemorrhage of tonsils, pediatric autoimmune neuropsychiatric disorder associated with streptococci
(PANDAS), and chronic group A streptococcus.4 For children who are
carriers of group A streptococcus, it is important to evaluate for symptoms, family history of rheumatic heart disease or glomerulonephritis, and frequent spread of infection within the household. Tonsillectomy for unilateral tonsil enlargement is sometimes performed out
of concern of a malignant neoplasm. However, one tonsil fossa is often more shallow than the other, which gives the perception that a
tonsil is enlarged. Malignant neoplasm was only found for children
with asymmetrically enlarged tonsils if there were suspicious clinical symptoms.29 Tonsillar asymmetry without associated risk factors is not an indication for surgery.

Contraindications
The contraindications for adenotonsillectomy include hematologic
disorders, active infection, and uncontrolled systemic disease; in
addition, the risk of velopharyngeal insufficiency should be
considered.30 Conditions that may place a child at risk for velophajamapediatrics.com

SDB Signs/Symptoms
Daytime
Attention-deficit/
hyperactivity disorder
Sleepiness
Learning problems
Behavioral problems

A management pathway for children

who may benefit from an
adenotonsillectomy. GAS indicates
group A streptococcus;
PFAPA, periodic fever, aphthous
stomatitis, pharyngitis, and cervical
adenitis; and SDB, sleep-disordered
breathing.

ryngeal insufficiency include cleft palate, submucous cleft, bifid

uvula, short palate, or neuromuscular disorder. Velopharyngeal
insufficiency should be considered a relative contraindication. If a
child is at risk for velopharyngeal insufficiency and undergoes
adenotonsillectomy, he or she may have worsening of speech;
extra adenoid tissue is left at the Passavant ridge so that the soft
palate can still close the nasopharynx.30 Concern for bleeding is
discussed in detail below; untreated hematologic disorder is a definite contraindication. Finally, active infection (with the exception of
peritonsillar abscess) and uncontrolled systemic disease are also
definite contraindications.

Perioperative Issues
Hematologic Evaluation
Postoperative hemorrhage is a potential complication of adenotonsillectomy. Primary postoperative hemorrhage occurs within 24
hours of surgery, while secondary postoperative hemorrhage occurs after 24 hours. The most common time for a secondary hemorrhage is 6 days after adenotonsillectomy.31 Rates of hemorrhage
vary, but 2 large prospective studies estimated primary and secondary hemorrhage rates at 0.6% to 0.7% and 0.8% to 3%.32,33 Although hemorrhage is relatively uncommon and may resolve spontaneously, it can be devastating. Reviews of settlement cases related
to adenotonsillectomy revealed that postoperative hemorrhage was
the most frequent cause of death and malpractice claims,34,35 highlighting the importance of preoperative assessment for bleeding risk.
Children should avoid taking aspirin or other anticoagulants at least
10 days prior to adenotonsillectomy.
Previous studies have demonstrated mixed results with respect to the ability of coagulation studies to predict hemorrhage af(Reprinted) JAMA Pediatrics Published online October 5, 2015

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ter adenotonsillectomy.36-44 A meta-analysis of bleeding after tonsillectomy demonstrated no difference in rates of postoperative
bleeding in patients with or without abnormal results on preoperative coagulation studies.41 That said, a recent report examining children and young adults with known bleeding disorders found a high
incidence of postoperative bleeding at 53%, with delayed bleeding
(>24 hours after the surgical procedure) more common than early
bleeding.45 Others have found that while a history negative for bleeding disorders and normal results on coagulation tests both have excellent negative predictive values, they have poor positive predictive values for postoperative bleeding. 44 Taken together, the
available evidence supports assessing for a history of patient or family bleeding diathesis in all patients, coagulation testing in children
with a questionable or unknown history of bleeding disorders (with
prothrombin time, partial thromboplastin time, complete blood cell
count, and platelet function assay), and a low threshold for formal
preoperative hematologic consultation in those with abnormal test
results or a known bleeding disorder.

Perioperative Antimicrobial Prophylaxis

Infection associated with adenotonsillectomy is thought to be
related to postoperative hemorrhage, halitosis, fever, pain, and oral
intake and as such has been the target of prior investigations. Normally after adenotonsillectomy the wound is contaminated by oropharyngeal bacteria. Infection in this context is difficult to define
but signified by fever, prolonged inability to eat, or worsening
pain.46 The first randomized, placebo-controlled, clinical trial evaluating the effect of intraoperative antibiotics on recovery after
adenotonsillectomy demonstrated promising results, with less
pain, lassitude, halitosis, and improved oral intake.47 However, one
meta-analysis46 failed to demonstrate consistent evidence for clinically meaningful improvement in postoperative pain or hemorrhage with antibiotic prophylaxis, resulting in the current American
Academy of OtolaryngologyHead and Neck Surgery recommendation against routinely administering perioperative antibiotics for
adenotonsillectomy.4

Inpatient vs Outpatient
Although adenotonsillectomy is most commonly a same-day surgical procedure, some children warrant inpatient treatment. Selected conditions or patient characteristics increase the risk for postoperative complications, mainly airway compromise, and form the
basis for planned inpatient management. Hospitalization is recommended for children younger than 3 years, those with severe OSA
(AHI >10 events per hour or oxygen saturation nadir <80%), and
those with complicated medical histories, such as cardiac disease,
neuromuscular disorders, former prematurity, failure to thrive, craniofacial anomalies, or recent respiratory infection.4 Respiratory infection may be as mild as an upper respiratory tract infection, with
increased risk of adverse events if peak symptoms occur within the
4 weeks preceding surgery48; in this situation, adenotonsillectomy
is often delayed to allow full recovery from the illness.

Operative Technique
The most common technique is extracapsular tonsillectomy, in
which the entire tonsil and surrounding capsule are removed. However, in an effort to decrease the rate of complications, subtotal
tonsillectomy (tonsillotomy) has been investigated. A recent metaE4

analysis comparing tonsillectomy with subtotal resection found

that although tonsillotomy was superior in the short term because
of lower complication rates, the patients undergoing tonsillotomy
had higher recurrence of SDB symptoms,49 which may be owing to
tonsillar regrowth.

Pain Control
Throat and ear pain are common following adenotonsillectomy and
can typically remain bothersome for up to 2 weeks.50,51 Administration of intravenous dexamethasone has been shown to decrease postoperative pain, nausea, and vomiting.52 The recommended first-line postoperative analgesics are acetaminophen with
or without ibuprofen.4 Although acetaminophen with codeine was
used commonly in the past, it has not been shown to provide superior pain control compared with acetaminophen alone.53 While
there is a theoretical risk of ibuprofen use leading to increased postoperative bleeding, this adverse event has not been observed in
several trials.54-57 There is evidence that ketorolac and aspirin are
associated with increased bleeding risk.54,57 The benefit of fixed vs
as-needed schedules for analgesics is unresolved, but results from
one trial did demonstrate superior pain control with a fixed
schedule.58 Owing to the risk of oversedation, we do not advocate a
fixed schedule with opioids.
Opioid use should be limited in children following adenotonsillectomy. A recent study found that acetaminophen in combination
with morphine resulted in more frequent oxygen desaturations vs
acetaminophen combined with ibuprofen.59 More important, codeine is metabolized variably owing to inherited differences in the
cytochrome P450 pathway, which can lead to either ineffective pain
control or overdose. Recently, the US Food and Drug Administration added a black box warning to codeine indicating that it is contraindicated in children following adenotonsillectomy.60 For children who cannot tolerate oral intake in the postoperative period,
rectal administration of acetaminophen is an option. Reintroducing oral intake should be as tolerated; there is no evidence that restricting diet to soft foods and liquids in the immediate postoperative period reduces risk of complications.61,62
The above evidence suggests that scheduled acetaminophen
with or without ibuprofen is the best analgesic regimen in the
immediate postoperative period, with as-needed oxycodone
therapy used sparingly. Some institutions recommend oxycodone
only in children older than 5 years, but this guideline is not universally accepted.

Special Populations
Children with sickle cell disease should have a formal preoperative
evaluation with a hematologist, preoperative PSG, and postoperative inpatient observation given their increased risk for complications associated with hypoxemia and dehydration.11,63 Children with
Down syndrome have a higher risk of atlantoaxial instability; therefore, the surgical team should take precautions with the patients
neck flexion and extension while asleep.64 Currently, the AAP recommends cervical spine radiographs in children with Down syndrome who have neurologic signs or symptoms of instability but not
in asymptomatic children.64 Finally, as noted above, velopharyngeal insufficiency is a potential adverse effect of adenotonsillectomy; thus, careful preoperative evaluation of the palate for a submucous cleft is important.

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Potential Complications

tranasal corticosteroids and leukotriene inhibitors for children with

nonsevere OSA.73-76 Therefore, using PSG to differentiate severe from
nonsevere OSA may appropriately identify candidates for medical,
ratherthansurgical,therapy,whichmaybeofspecialimportancegiven
the substantial proportion of children with mild OSA who have spontaneous resolution.5
In the face of different parent medical organizations providing
different guidelines for the use of preoperative PSG in the otherwise healthy child with SDB, we suggested the following approach.69
Based on history and physical examination findings, assess for (1)
nighttime symptoms: habitual snoring, gasping, pausing or struggling to breathe; (2) daytime symptoms: unrefreshed from sleep, attention deficit, hyperactivity, emotional lability, temperamental, poor
weight gain; and (3) enlarged tonsils. If all 3 factors are present, then
proceed with adenotonsillectomy without preoperative PSG. If the
child does not have all 3 factors, assess for other indications for adenotonsillectomy and, if they are present, proceed with surgery without PSG. One is more confident that a child may have SDB secondary to the tonsils when they are noted to be hypertrophic, although
previous studies have demonstrated a weak association between
tonsil size and OSA severity.77

As noted above, the rates of postoperative hemorrhage vary but range

between 0.6% and 3.0%. Upper airway obstruction in the immediate postoperative period is associated with more severe preoperative OSA, age younger than 3 years, craniofacial abnormalities, failure to thrive, neuromuscular disorders, and obesity.65 Laryngospasm
and bronchospasm related to anesthesia occur in approximately 1.6%
and1.8%,respectively,ofpatientsundergoingadenotonsillectomyand
are highly associated with a history of asthma.66 Transient pain, nausea and vomiting, mild dehydration, and halitosis are not considered
complications but rather are expected occurrences in the immediate postoperative period. The rate of readmission following adenotonsillectomy is 3.9%, primarily owing to uncontrolled pain, vomiting, and
hemorrhage.4 Mortality associated with adenotonsillectomy is low,
with estimates ranging from 1 in 12 000 to 1 in 35 000.67

Controversies
Role of Preoperative PSG
The role of preoperative PSG remains controversial. The AAP guidelines recommend routine preoperative PSG for proper diagnosis of
OSA when available, but also leave an option for referral to an otolaryngologist or sleep specialist.8,68 The rationale for routine PSG is that
history and physical examination alone lack sufficient accuracy for
proper diagnosis and that formal PSG can quantify the severity of baseline OSA, which may be helpful for selection of treatment and perioperative planning.8 The contrasting viewpoint is that preoperative
PSG should be reserved for patients with selected conditions or those
with a discrepancy between tonsil size on examination and reported
history.11 The rationale for this approach is that the role of PSG is to
improve diagnostic accuracy and severity assessment to avoid unnecessary surgery and help determine postoperative level of care in
children at higher risk of perioperative respiratory compromise.11 In
our opinion, PSG, like any other test, should be performed only when
the results have the potential to alter patient management. Therefore, it makes sense to perform this test when the child is at higher
perioperative risk, when adenotonsillectomy is unlikely to be curative, when parents request objective diagnosis prior to surgery, or
when history and examination are inconsistent.69
The real controversy is the utility of preoperative PSG in otherwisegenerallyhealthychildrenwithaclinicaldiagnosisofSDBandlarge
tonsils. Results of a PSG would be able to differentiate children with
snoring without frank OSA diagnosed via PSG (primary snorers) from
those who meet the American Academy of Sleep Medicine criteria for
OSA. This distinction would be of clinical importance if the 2 conditions were associated with different morbidity or responded differently to treatment. However, some studies demonstrate a similar degree of neurocognitive deficits in children with primary snoring
compared with those with frank OSA.70,71 Furthermore, in a study in
which children with SDB but PSG results negative for OSA were randomized to undergo either adenotonsillectomy or observation alone,
those who underwent adenotonsillectomy had significant improvements in SDB symptoms compared with those who received
observation.72 Results from CHAT also demonstrate a very mild, if any,
association between OSA severity as assessed by PSG and baseline
morbidity or response to adenotonsillectomy.18,19 On the other hand,
a growing body of evidence may support a role for treatment with injamapediatrics.com

Weight Gain
Previous reports have demonstrated increased weight gain in children following adenotonsillectomy.20 In children who are categorized as having failure to thrive at baseline, this weight gain may be
beneficial. In contrast, in children who are overweight or of normal
weight at baseline, this weight gain could increase their risk of obesity. For example, in CHAT, children who were overweight at baseline
had a 52% chance of becoming frankly obese following adenotonsillectomy20; the authors speculated that growth alterations could
be related to increased calorie intake, decreased calorie expenditure
related to less work required to breathe at night, decreased intermittenthypoxemia,decreaseddaytimehyperactivity,orincreasedgrowth
hormone secretion. Therefore, encouraging proper fitness and nutrition in children following adenotonsillectomy may be important.

Immune Function
Because the tonsils and adenoids are lymphatic tissue, a reasonable
question is whether removing those tissues will affect a childs immune function. One review found 27 studies, 21 of which demonstrated no effect of adenotonsillectomy on immune function.78 Furthermore, immunoglobulin levels have been shown to remain
adequate following adenotonsillectomy.78-80 The available evidence suggests that adenotonsillectomy will not place a child at increased risk for infection.

Conclusions
Adenotonsillectomy is a common surgical procedure that is usually
performed for SDB or recurrent throat infections in children. The
available evidence suggests that adenotonsillectomy is effective for
SDB and severe recurrent throat infections and that preoperative
PSG for OSA should be performed in patients for whom the results
directly affect management decisions. Future studies are needed to
evaluate the role of adenotonsillectomy for SDB in populations beyond generally healthy children.
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7. Erichsen D, Godoy C, Grnse F, Axelsson J, Rubin

D, Gozal D. Screening for sleep disorders in
pediatric primary care: are we there yet? Clin
Pediatr (Phila). 2012;51(12):1125-1129.

ARTICLE INFORMATION
Accepted for Publication: June 11, 2015.
Published Online: October 5, 2015.
doi:10.1001/jamapediatrics.2015.2016.
Author Affiliations: Division of Pulmonary and
Sleep Medicine, Childrens Mercy Hospital, Kansas
City, Missouri (Ingram); Division of Pediatric
Otolaryngology, Childrens Hospital Colorado,
Aurora (Friedman); Department of Otolaryngology,
University of Colorado School of Medicine, Aurora
(Friedman).
Author Contributions: Drs Ingram and Friedman
had full access to all the data in the study and take
responsibility for the integrity of the data and the
accuracy of the data analysis.
Study concept and design: Both authors.
Acquisition, analysis, or interpretation of data:
Ingram.
Drafting of the manuscript: Both authors.
Critical revision of the manuscript for important
intellectual content: Both authors.
Administrative, technical, or material support: Both
authors.
Conflict of Interest Disclosures: Dr Friedman is a
member of the American Board of Internal
Medicine (ABIM) Board of Directors and of the
ABIM Internal Medicine Examination Committee. To
protect the integrity of board certification, ABIM
strictly enforces the confidentiality and its
ownership of ABIM examination content, and Dr
Friedman has agreed to keep ABIM examination
content confidential. No ABIM examination content
is shared or otherwise disclosed in this article. No
other disclosures were reported.
Additional Contributions: Jacob Fish, MD, Sanford
Health, provided comments regarding an earlier
version of this manuscript and Amanda G. Ruiz, BA,
Department of Otolaryngology, University of
Colorado School of Medicine and Childrens
Hospital Colorado, assisted in preparing the figure.
They were not compensated for their contributions.
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